ML17058A691

can

be physically

carried out in the plant,

and that the

NMP2

can

be

implemented

by the

plant staff.

The inspection

team concluded that the

NMP2 EOPs are technically

correct,

can

be physically carried out in the plant,

and

can

be implemented

by

the plant staff.

The inspection

team performed

a technical- review of the

NMP2 Plant Specific

Technical Guideline

(PSTG)

and

and concluded that the various

developed

by the facility were sufficient to meet the intent of the

BWR Owners

Group

(BWROG) Emergency

Procedure

Guidelines

(EPGs).

The

NMP2

EOPs were,

in

general,

technically adequate

and, if implemented properly,

could safely

mitigate the accident conditions they are designed, for.

The licensee

deviated

very little from the

EPG and the deviations

taken were, with one noted

exception,

adequately justified.

The inspection

team questioned

the technical

adequacy

of the justification for the omission of main

steam tunnel

temperatures

as

an entry condition for an

EOP.

A number ov'nconsistencies

and deficiencies

were identified in the

EOP support

procedures

which indicated weaknesses

in the

verification and validation (V8V) process.

The inspection

team performed

a review to determine if the

EOP flowcharts

and

N2-EOP-6,

"NMP2

EOP Support Procedure,"

could be implemented

by the operators

and carried out in the plant.

The operators'erformance

on the simulator and

participation in the plant walkdowns indicated that the operators

were properly

trained,

had

a thorough understanding

of the

EOP bases,

and could correctly

implement the

EOPs in emergency situations.

Inconsistencies

that could lead to

confusion were identified in the

EOP support procedures

during the plant

walkdowns.

These inconsistencies

were further indications of weaknesses

in the

V5V that was performed

on the

N2-EOP-6 attachments

and other procedures

that

support the

The licensee's

method for prestaging

EOP tools could lead to

confusion or delays

in the implementation of the procedure.

Additionally, the

licensee's

method of storing jumpers in packets

located inside electrical

panels

could impact the qualification of those electrical

panels.

The

human factors review indicated

the

NMP2

EOPs were generally understandable

and usable

by operators

to mitigate

an emergency.

In addition, it'as

noted

that the

EOP writer's guide reflected

an effort to address

some of the most

significant industry issues

on

EOPs identified in previous inspections.

The

inspectors

noted

some weaknesses

within the writer's guide that appear to have

reduced

the quality of the

EOPs, especially

N2-EOP-6.

The inspection-team

reviewed the licensee's

program for ongoing evaluation of

the

They concluded that the licensee

had established

a sound

program for

ongoing

EOP evaluation

and for implementing

changes to'he

The inspec-

tors were concerned

that the licensee's

controls for issuing temporary

changes

to the

and

EOP support procedures

are too flexible and do not assure

that

changes

to these

procedures will receive- the proper

level of review.

The

inspection

team also reviewed the licensee's

QA involvement in the

EOP program

and concluded that Niagara

Mohawk QA Department is effective in identifying

problems

and assuring

the quality of the

The licensee's

gA program appears

to be effective since

a number of NRC inspect-

ion team concerns

identified in this report

had already

been

independently

identified by the most recent

gA audit.

Overall, the inspection

team also concluded that -the licensee

had devoted

sufficient resources

to the development of the

The result was procedures

that can

be effectively implemented.

The operators'nderstanding

of the

bases

and ability to use the

EOPs were considered

a strength.

There were

some

technical deficiencies

and

h'uman factors issues identified, mostly within the

EOP support procedures.

The majority of the problems

appear to be the result

of weaknesses

within the verification and validation process for the

support procedures.

Additionally, the licensee

was receptive

to the inspection

team's

comments

and committed to appropriately disposition the issues

raised

during this inspection.

DETAILS

~Back round

Following the Three Mile Island (TMI) accident

the Office of Nuclear

Reactor Regulation

developed

the

"TMI Action Plan"

(NUREG-0660

and

NUREG-0737) which required licensees

of operating

reactors

to reanalyze

transients

and accidents

and to upgrade

emergency

operating

procedures

(EOPs)

(Item I.C. 1).

The plan also required the

NRC staff to develop

a

long-term plan that integrated

and expanded efforts in. the writing,

reviewing,

and monitoring of plant procedures

(Item I.C.9).

NUREG-0899,

"Guidelines for the Preparation

of Emergency Operating

Procedures,"

represents

the

NRC staff's long-term program for upgrading

EOPs,

and

describes

the

use of a "Procedure

Generation

Package"

(PGP) to prepare

The licensees

formed four vendor type owner groups corresponding

to the four major reactor types in the United States.

Working with

General Electric and the

NRC, the Boiling Water Reactor

Owners

Group

(BWROG) developed

the

BWR Emergency

Procedure

Guidelines

(EPGs) which are

generic

procedures

that

sec forth the desired

BWROG accident mitigation

strategy.

The

EPGs were to be used

by the licensees

in developing their

PGPs.

Submittal of the

PGP was

made

a requirement

by Generic Letter 82-33,

"Supplement

1 to NUREG-0737,

Requirements

for Emergency

Response

Capability."

The generic letter requires

each licensee

to submit

a

PGP

which includes:

(i)

Plant-specific technical

guidelines

(ii) A writers guide

(iii)Adescription of the program to be used for the validation of EOPs

(iv) A, description of the training program for the upgraded

From this

PGP, plant specific

EOPs were to have

been developed that would

provide the operator with the directions to mitigate the consequences

of a

broad

range of accidents

and multiple equipment failures.

From January

28

February

1,

1991,

an

NRC team of inspectors

consisting

of three

NRC licensed operator examiners/inspectors,

a reactor

systems

specialist,

a

human factors specialist,

and the resident

inspector

conducted

an inspection of the

EOPs at the Nine Mile Point Nuclear Station

Unit 2 (NMP2).

NMP2 is

a

BWR 5 with a Hark II containment

structure.

The

objectives of the inspection

were to determine if:

the

NMP2

EOPs are

technically correct;

the

NMP2

can

be physically carried out in the

plant;

and that the

NHP2

can

be performed

by the plant staff.

The objectives

would be considered

to be met if the results of the

following reviews were found to be adequate:

comparison of the

NMP2

with the

NMP2 plant specific technical

guidelines

(PSTG)

and the

EPGs;

review of the technical

adequacy

of the deviations

from the

EPGs; control

room and plant walkdowns of the

NMP2 EOPs;

real time evalu-

ation of the

NMP2

on the plant simulator; evaluation of the licensee

program

on continuing improvement of the

NMP2 EOPs;

and performance of a

human factors analysis of the

NMP2 EOPs.

The inspection

focused

on the

adequacy of the

end product,

the

NMP2 EOPs.

If any of the areas

were not

found to be acceptable,

the inspection

would assess

other areas

as

necessary

to understand

the basis for the deficiencies.

The

PGP for NMP2 was submitted to the

NRC in a letter dated

June

29,

1984.

The Safety Evaluation for the

NMP2

PGP

was issued

in February

1985.

The

NMP2

EOPs were

implemented i.nitially in October

1986.

These

implemented

Rev.

3 of the

The facility utilized the

NMP2

PSTG, writers guide,

and verification and validation

(V&V) program

as

described

ir the procedures

generation

package

submitted to the

NRC in

June

1984. lo aetermine

the

success

of the implementation of licensee

programs,

a se'ies

of NRC inspections

of EOPs were conducted

in 1988 which

examined the final product of the program,

the

The results of the

NRC inspections

conducted

during

1988 were

summarized

in NUREG-1358,

"Lessons

Learned

from the Special

Inspection

Program for Emergency

Operating

Procedures."

This inspection

was conducted

following the

implementation of a major revision to the

EOPs that implemented

Rev.

4 of

the

EPGs

as part of the continuing effort of the

NRC to evaluate

EOPs at licensee facilities.

The facility has modified their administrative

program controls

and

EOP development

process

since the initial revision of

the

NMP2

EOPs following issuance

of NUREG-1358.

2.0

Persons

Contacted

k

B

J

R

M.

J.

R

M.

R.

G

P.

J

t

Sylvia, Executive Vice President - Nuclear Division

Firlit, Vice President

Nuclear Generation

Abbott, Unit 2 Plant Manager

McCormick, Unit 2 Plant Manager designate

Wi lczek, Jr.,

Vice President - Nuclear Support

Perry,

Vice President

equality Assurance

Smith, Training Manager

Colomb, Operations

Manager

Seifried,

General

Supervisor

Operations Training

Slade,

Supervisor - Operations

Training Unit 2

Corbin, Supervisor - Simulator Tech.

Walsh,

Licensed Operator. Instructor

Helker, Operations

Supervisor

I

L. Naron, Generation

Engineer

J. Kronenbitter,

Generation

Engineer

(NMPl)

K. Iandolo,

Engineer

C. Kolod, System

Engineer

G. Lapinsky,

Program

Development

~

J. Burton, Supervisor.-

QA Audits

J.

Burgess,

QA Technician

P. Fodi,

18C Technician

M. Goldych, Site Licensing

J.

Pavel,

Li'censing Engineer

K. Korcz, Licensing Engineer

N. Rademacher,

Executive Assistant to Exec.

Vice President

A. Mattessich,

Operations

Assessment

(MATS)

E.

Dunn, Unit 2 Project

Engineer

The inspectors

also contacted

other licensed

and nonlicensed

operators.

Other

R. Brown, Requalification Instructor,

General

Physics

B. Hennigan,

Requalification Instructor,

General

Physics

R. Klein,

Human Factors,

ARD

M. Yeminy, Engineer,

SWEC

Nuclear

Re viator

Commission

L. Bettenhausen,

Chief, Operations

Branch,

DRS

W. Cook, Senior Resident

Inspector

Denotes

those

present

at the exit interview on February

1,

1991.

3.0

Basic

EOP/BWR Owners

Grou

EPG

Com arison

~Sco

e

A comparison of the

NMP2

and

BWR Owners

Group

Emergency

Procedure

Guidelines

(BWROG EPGs),

Revision 4,

was conducted

to ensure that the

licensee

has developed

the procedures

indicated in the

The

EOPs reviewed are listed in Attachment

A of this report.

~Findin

s

The facility developed

EOPs that mimic the types of symptom based

procedures

recommended

by the

The inspection

team found no

deviations

between

the types of procedures

developed

by the facility and

the types of procedures

recommended

by the

Conclusions

The inspection

team concluded that the various types of EOPs developed

by the facility were sufficient to meet the intent of the

4.0

Inde endent

Technical

Ade uac

Review of the

Emer enc

0 crating

Procedures

~Sco

e

The

NMP2

EOPs listed in Attachment

A were reviewed to assure

that the

procedures

are technically adequate

and accurately

incorporate

the

EPGs.

A comparison of the

NMP2

PSTG to the

BWROG EPGs

and

NMP2 EOPs

was

also performed.

Differences

between

the

BWROG EPGs

and

NMP2

PSTG were

assessed

for adequate

technical justification.

Selected

specific values

from the procedures

were reviewed to determine that the values

were

correct.

~Findin

s

4. 1

Com arison of

EPGs

and

NMP2

PSTG

In general,

the differences

between

the

EPGs

and the

NMP2

PSTG

have adequate

technical justification.

The inspection

team noted

several

instances

in which the deviations

between

the

EPG and

the

NMP2

PSTG were due to more conservative

requirements

established

by the licensees

The inspection

team identified one deviation that did not appear to

have adequate

technical justification.

The licensee

did not include

main

steam tunnel

temperature

as

an entry condition to N2-EOP-SC,

"Secondary

Containment Control."

The licensee

had deliberately

omitted main steam tunnel

temperature

since the

NMP2 main steam

tunnel is not part of secondary

containment.

One of the purposes

of

Secondary

Containment Control is to limit the reactivity release

from

secondary

containment.

A steam line break in the main

steam tunnel

would bypass

secondary

containment

and could result in

a radioactive

release.

Elevated

main

steam tunnel

temperatures

are indicative of a

problem that should

be addressed

by an

EOP.

The licensee

has

agreed

to review the

need to add the main

steam tunnel

temperature

to

N2-EOP-SC or N2-EOP-RR, "Radioactivity Release

Control."

4.2

Com arison of NMP2 PSTG and

NMP2

In general,

the differences

between

the

NMP2

PSTG and the

NMP2

(variances)

have

adequate

technical justification.

The

PSTG vari-

ances

are properly utilized.

However, the inspection

team identified

several

variances

that did not appear

to be adequately justified or

utilized properly.

The

PSTG section for N2-EOP-PC, specifically the hydrogen control

leg, states

that El.

217 ft. suppression

pool level is the transition

point between

purging the containment directly or purging through the

suppression

pool.

The

EOP states

El.

201 ft. suppression

pool level

as the transition point.

The licensee's justification for the

variance

may not be technically adequate.

The licensee

contends that

the negative

aspect

of the additional

containment pressurization

at

a

higher suppression

pool water level outweighs

the added benefit from

scrubbing

hydrogen through the suppression

pool water.

The licensee

has this item listed as

an

open item in accordance

with N2-ODI-5. 10,

'EOP

Ongoing Evaluation

Program,"

and plans to address

the issue with

the

BWROG in February

1991.

The inspection

team identified several

differences

between

the

PSTG

and the

EOPs that did not have variances

to justify them.

For

example,

the

NMP2

PSTG,

step

PC/H 4.2, directs venting the drywell if

the suppression

chamber

cannot

be vented.

However,

the

EOP itself does

not

direct the drywell to be vented if the suppression

chamber

cannot

be

vented.

The

EOP,

as written, does not accomplish

the, intent of the

PSTG step,

and the

PSTG does

not justify the variance

between

the

PSTG and the

EOP.

The licensee

agreed

to review the unjustified

variances

and

make appropriate

changes.

4.3

Site specific procedure

numbers

are referenced

in the

NMP2

PSTG for

tasks that are accomplished

by the

EOP support procedures.

The

PSTG

is intended to describe

the

EOP strategy,

not the specific procedures

that. accomplish

the actions.

Referencing specific procedure

numbers

in the

PSTG can result in errors if the referenced

procedures

are

modified.

For example,

the

NMP2

PSTG incorrectly references

N2-EOP-6, Attachment

18, for venting the

RPV.

N2-EOP-6, Attachment

12, provides direction for venting the

RPV.

I

Technical

Ade uac

of EOPs

The inspection

team identified several

deficiencies with the tech-

nical

adequacy

of the

EOP flowchart procedures,

the

EOP contingency

procedures

and the

EOP support procedures.

The deficiencies

iden-

tified did not pose

immediate safety concerns;

however, 'they

represented

inconsistencies

that

a more thorough validation and

verification (Y8V) program should

have prevented.

Attachment

B

contains detailed technical

adequacy

comments.

The majority of deficiencies identified by the inspection

team were

found in procedure

N2-EOP-6,

"NMP2

EOP Support Procedure."

The

different attachments

in N2-EOP-6 were not consistently written.

Several

attachments

did not include restoration

steps

or give

adequate

guidance

on the success

criteria for .individual steps.

For

example,

Attachment

17, "Backfilling MSIVs," does not provide guid-

ance for securing

the backfill.

The inspection

team identified the fact that several

N2-EOP-6

attachments

reference

procedures

that are inadequate

for accomplishing

the specified task.

For example,

N2-EOP-6,

Attachment

18, "Depressur-

izing the

RPV," directs the operator to use the

RCIC system to

depressurize

the

RPV in accordance

with procedure

N2-0P-.35.

However,

N2-OP-35 does not contain procedural

guidance for operating

the

RCIC

system in the pressure

control

mode.

4.4

Technical

Ade uac

of Calculations

The inspection

team reviewed the engineering

worksheets

for several

setpoints

and figures contained

in the

EOPs to evaluate

the technical

adequacy

of. the calculations.

Additionally, the inspection

team

interviewed the individuals who performed the engineering calcula-

tions.

The calculations that the inspection

team reviewed were found

to be technically adequate.

Conclusions

The inspection

team concluded that the

NMP2

EOPs were,

in general,

tech-

nically adequate

and, if implemented properly, could safely mitigate the

accident conditions for which they are designed.

The licensee

deviated

very little from the

EPG and the deviations

taken were,

in general,

adequately justified.

However,

the inspection

team noted several

proce-

dural inconsistencies

and technical deficiencies,

especially in the

support procedures.

These

problems

were not identified by the

V&V program

indicating weaknesses

in the program, especially with respect

to the

V&V

performed

on N2-EOP-6.

5.0

Control

Room and Plant Walkdowns

~Sco

e

The inspection

team walked

down the

and procedures

indicated in

Attachment

A to confirm that the procedures

can

be implemented

by the

staff and carried out in the plant.

The purposes

of the walkdowns were to

verify that instruments

and controls required to be used to implement the

procedures

are consistent

with the installed plant equipment;

ensure that

the indicators,

controls

and annunciators

referenced

in the procedures

are

available to the operator;

and ensure that the tasks

can

be accomplished.

The

EOP flowcharts were walked down in the plant control

room (versus

the

simulator)

and the N2-EOP-6 attachments

were walked

down both in the

control

room and in the plant.

~Findin

s

During

a walkdown of N2-EOP-6 Attachment

19,

"RWCU Boron Injection,".the

inspection

team noted that access

to the

RWCU precoat

room is severely

restricted

by tanks,

pipes

and valves.

About half of this equipment is

required

when using

a two component

mix (resin

and filter media) in the

RWCU

If

f

10

filter-demineralizers.

The licensee

now uses

a single

component mixture

(e.g.,

ECODEÃ); this eliminates

the

need for half of the equipment in the

room.

This permanently installed equipment,

which is

no longer used,

poses

severe restrictions to the implementation of the alternate

boron

inj'ection procedure.

A modification has

been developed

by the licensee

to

remove the obsolete

equipment.

The licensee

agreed to consider

upgrading

the priority of the modification for earlier implementation.

The inspection

team noted several

welding machines, lifting cages,

gas

bottles

and other portable

equipment either unrestrained

or tied to

safety related

equipment (e.g., cabling).

The problem was particularly

noticeable

on the

261 level of the reactor building.

The inspector

also

noted

flammable material (e.g.,

Poly Bags)

stored in combustible

material

exclusion

zones.

These

problems

were identified to the licensee

and appropriate corrective action

was taken.

The inspection

team noted that

EOP support procedures

(N2-EOP-6 attach-

ments) which involved the installation of jumpers in

1E cabinets (e.g.,

to

defeat interlocks)

had the jumpers prestaged

in the

1E cabinet.>.

The

required jumpers for each of the attachments

were stored

in open top

plastic

bags (e.g.', zip-lock Bags) which were taped to the

ins'~de of the

panel

doors.

In

some cases,

the tape (duct tape)

had

come partially loose

from the door, resulting in the jumper bags

being less

secure

than

intended.

The inspection

team questioned

licensee

personnel

as to the

propriety of having the jumpers stored

in this manner within the panels

and the effect on panel

equipment qualification.

The licensee

agreed to

perform

a technical

evaluation of the jumper storage

method.

In

a related

issue,

the inspection

team noted that the prestaged

jumpers

in relay room and control

room panels

are all numbered for the purpose

of

performing periodic'nventories.

The inspection

team noted that neither

the jumper tags

nor the support

procedure

attachments

specify which jumper

is to. be used for each of the terminal pairs being jumpered in the proce-

dures.

Since the jumpers are cut to length for each set of terminal

pairs,

the potential exists for an operator to use the longer jumpers

first, and

be left with only short jumpers for later sets of terminals

which are

more widely separated.

Several

of the panels

in the control

room and the relay room, which must

be accessed

for the insta'llation of

jumpers

and the lifting of leads during performance

of the

N2-EOP-6

attachments,

have

no external

labeling to indicate the individual bays

within the panel.

Additionally, there

are

no formally available

general

arrangement

drawings of the panel

layouts for the relay

room (i.e., either

as part of the procedures

or posted

as

an operator aid in the relay room).

The inspection

team noted that control

room and relay

room panels

were not

being consistently

locked,

as indicated either in procedures

or by labels

on the panel

doors (e.g.,

P 861,

Bay

E in the relay room).

Several

panels,

which either

had

a label requiring locking, or which the proce-

dures indicated would require

a key for entry, were found and left

unlocked.

0

11

The inspection

team noted that the format of the

N2-EOP-6 attachments

did

not provide

a concise

and timely method for the operators

to ascertain

and

assemble all of the tools

and components

necessary

to perform each proce-

dure in the field.

The procedures

required that the operator

scan the

entire procedure to look for tool

and component

requirements,

which. were

indicated with a "Circle T" in the procedure

margin.

Either by memory or

by writing down each of the requirements

on. a separate

piece of paper,

the

operator would then obtain the necessary

items from the

EOP tool boxes in

the control

room.

Although

some

EOP-support

procedure

items were pre-

staged

in the plant (e.g.,

hoses,

large wrenches,

and terminal jumpers),

the necessity

to determine

the

need for and obtain the other items (e.g.,

fuse

pullers, flashlights,

screwdrivers,

speed

wrenches,

etc.) presented

the

potential for an operator to enter the plant without all of the necessary

tools and introduce

an unnecessary

time delay.

During the walkdowns of N2-EOP-6 attachments,

the inspection

team noted

inconsistencies

in the identification of controls

and components

which had

to be manipulated

in performing the procedures.

Some in-plant components

and controls were identified by component

number only, while others

were

indicated

by combinations of number,

noun

name,

and location.

The licen-

see explained that the more limited descriptions

were applied to

components

with which operators

were most familiar, and that the more

comprehensive

descriptions

were applied to less familiar components.

The

stated

purpose

for this methodology

was to minimize the size

and wordiness

of the procedures..

The inspection

team found at least

two cases

where the

operators initially thought that field components

were operated

from the

.control

room,

when in fact they required local operation (e.g.,

2CNS-V261

'in Attachment 6).

In other instances,

confusion

was created

by the triple

component

numbering

scheme (e.g.,

2WCS-F1C1016,

2G36-

R022,

and G36-N0112

all referring to the

same

component

in Attachment 19).

In other proce-

dures (e.g.,

step

18. 1.4.b in Attachment 18), the procedure

implied that

valves,

such

as

AOV-10B and

D,

had thei r own control switches,

when in

fact they do not.

The inspection

team noted that the existing process

for

determining

the extent of component identification in the support proce-

dures

was not formalized in the Support. Procedure

Validation Checklist

contained

in N2-EOP-5.

The walkdowns identified several

examples of

components

whose labels did not match the

noun

name of the component

in

the N2-EOP-6 attachments.

Operator aids found throughout the plant included handwritten sections.

The use of handwriting in operator aids

can

lead to illegibility and

may

cause

the aid to be unusable.

Currently,

Procedure

S-SUP-6

, "Control

of Operator Aids," does not prohibit the

use of handwriting in operator

aids.

Attachment

B contains additional specific

comments

on certain

EOP procedure

sections

from the walkdowns.

Conclusions

The inspection

team concluded that,

in general,

the

EOP procedures

could

be implemented

by the staff and carried out in the plant.

However, the

0

12

procedures

displayed inconsistencies

that could lead to. confusion.

The

licensee's

method for prestaging

required

EOP tools could lead to

confusion or delays in implementation of the procedure.

Additionally, the

licensee's

method of prestaging certain

EOP tools

and equipment in packets

located inside the electrical

panel

may impact the qualification of those

electrical

panels.

The problems identified during the walk-down reflected

weaknesses

in the licensee's

validation and verification program,

espe-

cially with respect

N2-EOP-6.

6.0

Simulator

~Sco

e

Six scenarios

were administered

to two shift crews

on the plant specific

simulator.

The simulator scenarios

provided information

on the

operators'bility

to implement the

EOPs in

a real

time situation.

The purposes

of

this exercise

were to determine if the

EOPs provide operators with suffi-

cient guidance

such that their responsibilities

and required actions

during emergencies

both individually and

as

a team are clearly outlined;

verify that the procedures

do not cause

operators

to physically interfere

with each other while performing the

EOPs; verify that the procedures

do not duplicate operator actions

unless

reauired (i.e.,

independent

verification); and verify that transitions

between

procedures

are clear

and easily understood

by the operators.

~Findin

s

In general,

both crews observed

performed well during the three scenarios

that each

crew dealt with.

Both crews displayed

strong

teamwork and

communication skills.

The operators

understood

the

and were able to

effectively implement the procedures.

The inspection

team noted that the operators

inconsistently

used the

attachments

of N2-EOP-6,

"NMP2

EOP Support Procedure."

N2-EOP-6 contains

support

procedures

which are written in, a checklist format.. The procedure

clearly states

that the operators

are to place

a "check" opposite

each

step

as the steps

are completed.

The inspector

observed that the opera-

tors did not in all cases

refer to the attachments

of N2-EOP-6 for

operational

guidance

and that the operatoJ s,

when they did refer to the

procedure,

did not place

a "check" opposite

each

step

as it was completed.

Additionally, from direct questioning of the operators

at the completion

of the scenarios,

the inspection

team noted that the operators

did not

uniformly understand

the expectations

when using the N2-EOP-6 attach-

ments.

Some operators

thought that placing

a "check" opposite

each step

as

a placekeeping

method

was optional.

The inspection

team noted that

one crew did not clearly understand

the

injection system alignment requirements

for establishing

RPV flooding as

13

delineated

in N2-EOP-C4,

"RPV Flooding."

N2-EOP-C4 directs that injection

into the

RPV be controlled to maintain at least

4 SRVs

open

and at least

61 psid across

the

SRVs, the conditions required 'for RPV flooding.

N2-EOP-C4 indicates that the differential pressure

across

the

SRVs should

be

as

low as practicable,

which implies that injection sources

can

be (and

should be)

secured

to establish

the steady state conditions for RPV

flooding.

The crew misunderstood

the flooding directions

and believed

that injection sources

that are

used to establish

the conditions for

flooding cannot

be secured until the minimum core flooding interval time

was satisfied.

The inspection

team noted that several

reactor operators

were hesitant

in reporting

key parameter

changes

to the Station Shift Supervisor

(SSS).

There are certain

parameter

changes

that require

immediate notification of

the

SSS since these

parameters

influence the mitigation strategy of the

An example of a key parameter

change that requires

prompt

SSS

notification is the ability to determine reactor level.

One crew failed

to promptly report this parameter

change to the

SSS which resulted

in a

delay in entry into N2-EOP-C4,

"RPV Flooding."

Conclusions

The inspection

team concluded that the operators

were properly trained

in the

use of the

~

The operating

crews displayed

minor knowledge

and ability weaknesses,

but performed well overall.

The inspection

team

noted the operators'nconsistent

usage of .the attachments

of N2-EOP-6

reflecting weaknesses

in the training on EOP-6.

Overall, the operators

had

a thorough understanding

of the

EOP bases

and could correctly

implement the

EOPs in emergency situations.

7.0

Human Factors

Review of the

~Sco

e

A desk top review of the

NMP2

was conducted prior to the on-site

'inspection.

The review consisted

of an assessment

of the quality of N2-

EOP-5,'Production

and Control of NMP2

EOP Revisions"

(EOP writer's guide

and validation

and verification program),

and

a comparison of the

and

EOP support procedures

to ensure

they were generated

in accordance

with

N2-EOP-5.

Observation

of simulator exercises,

interviews with NMP2 staff,

plant walk downs,

and control

room tours were

used to both corroborate

those

items noted during the desk top review and to identify additional

concerns.

~Findin

s

7. 1

N2-EOP-6

NMP2

Su

ort Procedure

Considerable effort has

been di rected

toward the development of

guidance for procedure

structure

and content that supports operator

14

performance

through the application of human factors principles

Lack of application of this guidance to procedure

development

can

result in procedures

that are difficult to use

and

may lead to'rrors.

In some cases,

procedures

that do not complement

human capabilities

may inhibit performance,

rather than

enhance it.

The writer's guide for NMP2

EOPs included minimal guidance for

structure

and content for text procedures

and the validation check-

lists reflected the writer's guide weaknesses.

In addition,

N2-EOP-5

did not contain

a verification checklist for the

EOP support proce-

dures.

The lack of a verification checklist indicated that there

was

no structural

guidance

against

which to verify the procedures.

As

a

result,

N2-EOP-6

was found to have

numerous

inconsistencies

in

structure

and level of detail.

In

some cases,

steps

were technically

incorrect or could not be performed

as written (Section 4.3).

The

attachments

required

numerous transitions

to operating

procedures.

These transition 'steps failed to identify the necessary

sections

or

stens to be performed.

References

to plant labeling throughout

N2-LOP-6 were inconsistent with plant nomenclature

(Section 5.0).

In add tion, the sections

of operating

procedures

referenced

by

N2-EOP-6 were not subject to the validation requirements

of N2-EOP-6.

These

procedures

were not cross

referenced

to the.EOPs

in any way

that would ensure that structure,

content, verification,

and valida-

tion requirements

for EOPs would be applied to the referenced

procedures'.2

Communication

Between

0 erations

and Trainin

Natural

human variation in performance

is controlled by clear

and

consistent training

on the structure,

content,

and expected

execution

of EOPs.

Therefore, it is particularly important that clear two-way

communications

between

operations

departments

and training departments

exist regarding expectations

related to implementation of the

Any discrepancy

between

these

indicates

a weakness

in the

EOP system

and could lead to significant performance

problems

and possible error.

Several conflicts in definitions were identified between

the

NMP2

Operations

Department

EOP documents

and Training Department

documents.

Operators

provided conflicting definitions for important action verbs

used in the

EOPs which indicated

a disconnect

between

operations

and

training department

expectations.

The writer's guide developed

by

operations

personnel

included

some definitions that were missing from

the related

lesson

plan developed

by training..

7.3

N2-EOP-5

Production

and Control of NMP2

EOP Revisions

In order to prepare clear, consistent

EOPs that will support operator

performance

and minimize errors,

a complete

and restrictive writer'

guide is necessary.

A complete writer's guide addresses

every aspect

of the

EOPs;

a restrictive writer's guide defines clearly the precise

methods

and format to be used

in the

EOPs,

applying

human factors

15

principles.

Writer's guides that are

incomplete or nonrestrictive

leave format decisions to the writer's judgment

and preference.

Because

individual writer's judgments

vary, this could result in

increasingly inconsistent

and complex procedures.

In addition,

because

the writer's guide controls the consistent

presentation

of information within the procedures,

an incomplete or

nonrestrictive writer's guide

may lead to flawed verification.

The

resulting procedures

may be inconsistent

in structure

and content

and

therefore

more difficult for operators

to use,

resulting in a poten-

tial for error.

The

NMP2 writer's guide includes

a great deal of detail

and reflects

awareness

of current issues

and guidance

on

For example,

the

structure of caution

statements

is consistent

throughout

the

and

the cautions

do not contain actions.

The writer's guide is not

complete

and restrictive with respect

to

some aspects

of the

Some of the guidance within the writer'.s guide is unclear.

In

addition, the

NMP2

writer'-s guide. includes

some guidance that fails

to restrict procedure

structure.

Some important aspects

of proce-

dures

are not addressed,

such

as the structure of N2-EOP-6 (text

procedures).

Additionally, some of the guidance

included in the

NMP2

writer's guide is in conflict with standard

good practices for EOPs.

The verification and validation checklists

are extremely detailed

and

clearly intended to serve

as

a tool to support thorough

and consis-

tent verification and validation of the

However,

because

the

checklists

are essentially

reproductions

of the guidance

in the

writer's guide,

the writer's guide deficiencies

are proliferated

through the

use of these checklists.

Therefore,

the

V8V process

has

bhen

unable to prevent inconsistencies

in structure

and content

within the

EOPs, especially in EOP-6.

7.4

Flowcharts

As mentioned

above,

N2-EOP-5

was weak in

a

number

of important 'areas.

As

a result,

a number of inconsistencies

were found within the

flowcharts.

For example,

action

steps

were found included within

lists and action

symbols were found to include information that did

not require operator action.

In addition, the level of detail of

various

step

in the flowcharts varied

and in some

cases

appeared

to

be insufficient.

Conclusions

The team concluded that the

NMP2

EOPs were generally understandable

and

usable

by operators

to mitigate'n

emergency.

In addition, it was noted

that N2-EOP-5 reflected

an effort to address

some of the most significant

industry issues

on

EOPs in the last few years.

However, there were several

weaknesses

within N2-EOP-5 which resulted

in inconsistent quality of the

EOPs, especially

N2-EOP-6.

16

8.0

On oin

Evaluation of NMP2

~Sco

e

A review of the licensee's

procedures

and discussions

with licensee

personnel

were conducted to determine'he

effectiveness

of the licensee's

ongoing

EOP evaluation

program.

The ongoing evaluation

program

should

ensure

the technical

adequacy

and structural quality of the

EOPs in light

of operational

experience,

training experience,

control

room walkthroughs,

and from changes

in plant design;

technical specifications;

technical

guidelines;

or other plant procedures.

~Findin

s

Procedure

N2-ODI-5. 10,

"EOP Ongoing Evaluation Program," provides the

guidance

required to implement the ongoing evaluation

program.

It appears

.that the procedure

is adequate

and that the items currently listed in the

Open

Items

Logbook, generated

in accordance

with N2-ODI-5. 10,

have

been

properly prioritized and are being properly dispositioned.

Procedure

N2-EOP-5,

"Production

and Control of NMP2

EOP Revisions,"

provides the guidance

required to perform revisions to the

Speci-

fically, the procedure

delineates

the required verification and-validation

process for various types of revisions to the

The procedure

is

comprehensive

and appears

adequate

with the exception of the weaknesses

noted in the

V&V process

for the

EOP support procedures.

=

An

EOP Engineering

Impact Checklist is completed for each modification or

design

change

generated.

The purpose of the checklist is to ensure that

if there is

a potential

impact

on any aspect of the

EOPs or the

PSTG,

the,

appropriate

personnel

are informed

so that the

EOPs or

PSTG can

be revised

if needed.

The checklist itself has

been developed,

but training

on use

of the checklist will not be completed until March 31,

1991.

The check-

list is comprehensive

and appears

to be adequate

to ensure that the

are maintained current.

The inspector

had concerns that AP-2.0, "Production

and Control of Proce-

dures,"

does

not contain controls to ensure that the

EOP coordinator

performs

a review whenever

a temporary/publication

change

notice

(TCN) is

issued to an

EOP or an

EOP support procedure.

It is imperative that the

EOP coordinator performs

a review of all

EOP related procedural

changes

since the

EOPs consist of a mix of

EOP flowcharts,

EOP support procedures,

and specific operating

procedures

(OPs).

Additionally, the inspector

noted that AP-2.0 did not preclude

a

TCN from being issued to an

flowchart.

The licensee

committed to reviewing AP-2.0 and enhancing

controls

as

needed.

Conclusions

The inspector

concluded that the licensee

had established

a

sound

program for ongoing

EOP evaluation

and for implementing

changes

to the

0

17

However, the licensee's

controls for issuing

TCNs to the

and

EOP support

procedures

are too flexible and do not assure

that

TCNs

issued to these

procedures will receive the prope'r level of review.

9.0

ualit

Assurance

Measures

~Sco

e

The inspection

team reviewed the Quality Assurance

(QA) organization,

involvement in the programmatic

approach

of the

EOP program.

The inspec-

tion focused

on those policies,

procedures,

and instructions

necessary

to

provide

a planned

and periodic audit of the

EOP development

and implemen-

tation process.

The inspection

team reviewed the involvement of site

Quality Assurance

in the

EOP program

by interviewing Quality Assurance

Department

personnel

and by reviewing

a sample of past

QA Audits and

surveillances.

~Findin

s

The most recent

QA audit was conducted

in December

1990 in conjunction

with the final conversion of the Nine Mile Point Unit 2

from Revision

3 to Revision

4 of the

The

QA inspectors

used

NRC Temporary

Instruction 2515/92

as

a guide in performing the audit.

The audit was

noteworthy in that it identified over

50% of the technical

adequacy

issues

later .identified by the

NRC inspection

team in their pre-audit review of

the

same

EOP materials.

Many of the concerns identified by both the

Niagara

Mohawk QA auditors

and by the

NRC pre-audit technical

review had

been corrected

by the time the onsite portion of the

NRC

EOP audit

commenced.

A sampling of the audit concerns

showed that they had been

well documented

using the methods

specified in N2-ODI-5. 10,

"EOP Ongoing

Evaluation

Program."

The licensee

had initiated

some corrective actions

prior to this inspection.

The

EOP surveillance

conducted

in June

1990

used procedure

N2-EOP-5,

"Production

and Control of NMP2

EOP Revisions,"

and

NUREG-1358,

"Lessons

Learned

from the Special

Inspection

Program for EOPs,"

as guidance for

conducting the surveillance.

Concerns identified by the surveillance

had either been corrected

or are

scheduled

for correction.

Conclusions

The inspection

team concluded that Niagara

Mohawk QA Department involve-

ment in the

EOP program is satisfactory.

The licensee's

QA program

appears

to be effective since

a number of

NRC inspection

team concerns

identified in this report

had already

been

independently identified by the

most recent

QA audit.

10.0 Initial Examinations

During the course of the inspection,

the

NRC administered

a retake

exami-

nation to one reactor operator

(RO) license applicant.

The applicant

had

18

previously failed the simulator portion of the operating test,

but passed

the remaining portions of the examination.

The retake

examination

consisted

of only the simulator portion of the operating test.

The retake

examination

was administered

in accordance

with NUREG 1021,

Examiner

Standards

(ES)

Rev.

6, dated

June

1,

1990.

The applicant

passed

the retake examination;

therefore,

the applicant

has

now passed all portions of the

RO licensing examination.

Due to the

limited scope of this retake examination,

there

were

no generic

strengths

or weaknesses

noted.

11.0 Licensee Action on Previous

Ins ection Findin

s

CLOSED

410/89-12-01:'uring

an inspection of the implementation of

NRC

Bulletin 88-07

and Supplement

1,

BWR Power Oscillations,

conducted

in 1989,

the inspector

had concerns

that the licensee

had not conducted

a thorough

review of all operating

procedures

to incorporate

cautions that would

preclude

the operators

from entering

the unstable

operating

region of the

power-to-flow map.

The licensee

committed to conducting

an in-depth

review of all operating

procedures

to make

changes

as

needed.

A; a result

of the licensee's

review,

20 operating

procedures

were changed to preclude

operation in the unstable

region of the power-to-flow map.

The inspector

reviewed the licensee's

corrective actions

and found them acceptable.

Based

on the above, this item is considered

closed.

CLOSED

410/89-12-02

During an inspection of the implementation of NRC

Bulletin 88-07

and Supplement

1,

BWR Power Osci llations conducted

in 1989,

the inspector

had concerns

that the licensee

did not have

an operating

procedure that provided guidance for rapid power reductions.

The licensee

committed to developing

a

new procedure that would provide the guidance

needed to perform rapid power reductions.

The licensee

developed

proce-

dure N2-0P-101D,

Power Changes,

which provides

guidance for normal

power

changes

between

45% and

100% power

and

an off-normal section which

contains

the guidance for rapid power reductions.

The inspector

reviewed

the licensee',s

corrective actions

and found them acceptable.

Based

on the

above, this item is considered

closed.

CLOSED

410/89-10-01:

During

a licensed operator examination

conducted

in 1989, the examiner

had concerns

over the technical

basis of the method-

ology for actuating

a reactor

scram in procedure

N2-0P-78,

"Remote Shut-

down System."

The procedure directed the operator to initiate

a scram by

closing the NSIVs.

The licensee

committed to review the technical

basis

and

make revi sions if needed.

The licensee

revised

procedure

N2-OP-78 to

direct the operator to scram the reactor

by deenergizing

RPS

and then

closing the MSIVs.

This minimizes the transient

placed

on the reactor.

The inspector

reviewed the licensee's

corrective actions

and found them

acceptable.

Based

on the above, this item is considered

closed.

CLOSED

410/89-10-02

During

a licensed operator examination

conducted

in 1989,

the examiner

had concerns that the

EOP equipment

box 'required to

19

accomplish alternate

control rod insertion

by venting exhaust

header did

not contain all the equipment

necessary

to accomplish that task.

The

licensee

committed to verifying that all

EOP equi'pment'oxes

contained

the

equipment

necessary

to accomplish

the required task.

The licensee

developed

procedure

N2-PM-M4, "Monthly Audit of EOP Support

Equipment,"

which ensures

that each

EOP equipment

box contains

the necessary

equipment

and procedures

to accomplish

the .tasks

required

by the

The results

of the in-plant walkdowns of the

EOP support procedures

indicated that the

licensee's

corrective actions

were effective in assuring that equipment

was available to perform

EOP tasks.'ased

on the above, this item is

considered

closed.

CLOSED

410/90-16-01

During

a licensed operator

examination

conducted

in 1990, the examiner

performed

a review of the status of corrective

actions. performed

by the licensee

to correct deficiencies

noted during the

July 1989 Licensed Operator Requalification

Program Evaluation.

The

examiner

had concerns that three short-term corrective actions

and

one

long-term corrective actions

had not been

completed.

The licensee

has

since confirmed the completion of all the corrective actions

planned via

a

letter dated August 20,

1990,

and telephone

conversation

with the

NRC

staff on November 7,

1990.

The*inspector

reviewed the licensee's

correc-

tive actions

and found them acceptable.

Based

on the above, this item is

considered

closed.

12.0 Exit Interview

At the conclusion of the inspection

on February

1,

1991,

an exit meeting

was conducted with those

persons

indicated in paragraph

2.

The in'spection

~>'scope

and findings were summarized..

The licensee

did not identify as

proprietary

any of the materials

provided to or reviewed

by the inspectors

during the inspection.

Licensee'management

was

aware of the commitments

made

by the licensee's

staff during this inspectio'n

and agreed that all deficiencies

noted

by

the

NRC inspection

team would be addressed.

Attachments:

Attachment

A Documents

Reviewed

Attachment

B Detailed Technical

Adequacy

and Walkdown Comments

Attachment

C - Human Factors

Examples

Attachment

D - Simulation Facility Report

20

ATTACHMENT A

DOCUMENTS

REVIEWED-=

Flowchart

N2-EOP-RPV

" N2-EOP-PC,

N2-EOP-SC,

N2-EOP-RR,

~ N2-EOP-MSL

N2-EOP-C1,

N2-EOP-C2,

N2-EOP-C3,

" N2-EOP-C4,

N2-EOP-CS,

" N2-EOP-C6,

RPV Control,

Rev.

4

Primary Containment Control,

Rev.

4

Secondary

Containment Control,

Rev.

4

Radioactivity Release

Control,

Rev.

4'

MSIV Leakage Control,

Rev.

4

Alternate

Level Control,

Rev.

4

Emergency

RPV Depressurization,

Rev.

4

Steam Cooling,

Rev.

4

RPV Flooding,

Rev.

4

Level/Power Control,

Rev.

4

Primary Containment

F~ooding,

Rev.

4

Emer enc

Su

ort and Related

Procedures

Att.

Att.

Att.

Att.

Att.

Att.

Att.

Att.

Att.

Att.

Att.

Att.

Att.

Att.

Att.

Att.

Att,.

At%.

Att.

2.0-

3.0 "

4.0-

5.0-

6.0-

7.0-

8.0-

9.0-

10.0-

11.0 "

12.0-

13.0-

14.0-

15.0-

16.0-

17.0-

18.0-

19.0-

20.0-

21.0-

22.0-

23.0-

24.0-

25.0-

26.0-

27.0-

NZ-EOP-6,

NMP2

Att. 1.0-

Support Procedure,

Rev.

0

RPV Water Level/High Drywell Pressure

Associated

ESF

Actuations

Defeating

Low RPV Press

Isolation Interlocks

Throttling

ECCS Injection

Throttling RCIC Injection

RHR Service

Water Crosstie

RHR Firewater

System Crosstie

ECCS Keepfull

Pump Injection

Condensate

Transfer Injection

SLS Test Tank Transfer Injection

Depressurizing

the

RPV Using the Condenser

Defeating

RWCU Isolation Interlocks

Venting the

RPV

RRCS Manual Initiation

Alternate Control

Rod Insertions

SLC Hydro

Pump Injection

Use of SJAE with Aux Boiler Steam

Backfilling MSIVs

Depressurizing

the

RPV

RWCU Boron Injection

Defeating

L8

FWS Interlocks

Containment

Venting

Containment

Sprays

Containment

Level Determination

(above el

224 ft)

DW Unit Cooler Oper.

w/LOCA Signal

Containment

Purging

Defeating

HVR LOCA Isolation Signals

Restoration of H2/02 Analyzers

21

Att. 28.0

Determining Reactor. Building Temperatures

Att. 29.0

Determining Suppression

Chamber Overpressure

N2-0P-13,

Reactor Building Closed

Loop Cooling,

Rev.

2

N2-0P-30,

Control

Rod Drive, Rev.

3

N2-0P-31,

Residual

Heat Removal,

Rev.

7

N2-0P-32,

Low Pressure

Core Spray,

Rev.

3

" N2-0P-33,

High Pressure

Core Spray,

Rev

~

4

N2-0P-35,

Reactor

Core Isolation Cooling,'ev.

3

N2-0P-36A,

Standby Liquid Control,

Rev.

2

N2-0P-37,

Reactor

Water Cleanup

System,

Rev.

3

N2-0P-60,

Drywell Cooling,

Rev.

1

N2-0P-61A,

Primary Containment Ventilation, Purge,

and Nitrogen System,

Rev

~

3

N2-0P-61B,

Standby

Gas Treatment,

Rev.'5

N2-0P-62,

DBA Hydrogen Recombiner,

Rev.

4

N2-0P-101C,

Plant Shutdown,

Rev.

6

N2-0P-101D,

Power Changes,

Rev.

0

Administrative Controls

AP-2.0, Production

ana Control of Procedures,

Rev.

20

AI-1.0, Site Procedures

Writer's Guide

N2-EOP-5,

EOP Writer's Guide,

Rev.

1

S-SUP-6,

Control of Operator Aids, Rev.

1

N2-0DI-1.06, Verbal Communications,

Rev.

1

N2-0DI-1.08, Operations

Policy for Emergency

Procedures,

Rev.

4

N2-0DI-1.09,

EOP Users

Guide,

Rev.

4 (cancelled)

N2-ODI-5. 10,

EOP Ongoing Evaluation

Program,

Rev.

0

Other

Plant Specific Technical

Guidelines Input Parameters,

Rev.

2

NMP2

EOP Basis

Document

Calculations

Reviewed

Figure

PC-2 Drywell Spray Initiation Limit

Figure

PC-4 Primary Containment

Pressure

Limit

Figure

PC-8 Maximum Primary Containment

Water Level Limit

Suppression

Chamber

Spray Initiation Pressure

Limit (SCSIP)

" Denotes

those

procedures

walked-down

22

ATTACHMENT B

DETAILED TECHNICAL ADEQUACY AND WALKDOWN COMMENTS

N2-EOP-C4,

"RPV Flooding" does

not provide clear guidance for determining

that

RPV water level indication

has

become available.

Additionally, the

do not provide guidance

on when to backfill

RPV water level indication

reference

legs to restore

indication.

The definition in the

EOP bases

for "Gross

Fuel Failure" is three

times

normal

main

steam line radiation or three times

normal coolant activity.

It appears

the licensee

has

equated

these

two parameters

when in

actuality they may not indicate the

same

degree

of fuel failures

N2-EOP-PC,

"Primary Containment Control" directs the operator to operate

the hydrogen

recombiner in accordance

with N2-0P-62,

"DBA Hydrogen

Recombiner."

However,

N2-OP-62 contains

hydrogen

and oxygen limitations

that c.re more restrictive than what N2-EOP-PC requires.

The licensee

has tnis item l'isted as

an open

item in accordance

with N2-ODI-5. 10.

The fire hoses

which are required for the performance

of N2-EOP-6,

Attachment 6,

"RHR Firewater

System Crosstie,"

are

staged

'in

a locker in

the reactor building stairwell which is

1 floor below where they are

needed.

This concern

had already

been

documented

by the licensee

and

will be evaluated

to determine if the

hoses

can

be moved to

a location

closer to the

system interconnections.

N2-EOP-6,

Attachment 7,

"ECCS Keepfull

Pump Injection," specifies

the.

High Pressure

Core Spray

(HPCS) discharge

pressure

gage, be used to

determine that

ECCS keepfull pressure

is higher than

RPV pressure.

The

HPCS pressure

instrument line is upstream of the

HPCS discharge

piping

check valve, but the

ECCS keepfull flow enters

the

HPCS discharge

piping

downstream of the check valve.

Therefore,

the pressure

gage listed in

the procedure

would be isolated

from the

ECCS keepfull

pump and would

not provide accurate

indication

ECCS keepfull

pump discharge

pressure.

N2-EOP-6, Attachment 7,

"ECCS Keepfull

Pump Injection," step

7. 1.5,

does

not ensure that the

system is properly aligned for injections

Both

2CSH"MOV107 and

2CSH*V54 could be closed resulting in no flowpath for the

pumps

The licensee

agreed to add

a step to open

2CSH"V54

~

N2-EOP-6, Attachment 9,

"SLS Test Tank Injection," does

not contain

restoration

steps to replace

the squib valves.

The purpose of N2-EOP-6, Attachment

12, "Venting the

RPV," indicates that

the procedure

provides direction for venting the

RPV with the

RCIC system

and the

RHS

HX (steam

condensing)

system,

but the body of the procedure

does not contain, either of these

methods.

These

methods

are not used for

venting the

RPV,

so the licensee

agreed

to correct the purpose

to delete

the references

to

RCIC and

RHS

HX.

23

N2-EOP-6, Attachment

17, "Backfilling MSIVs," does

not contain restoration

steps

to restore

the leads lifted and the jumpers installed to execute

the

procedure.

Additionally, the procedure

does not provide clear guidance

for determining

the status of the NSIV backfill and determining

when the

backfill should

be secured.

The procedure

is written to rely on operator

experience

and judgement to determine

the status of the backfill.

N2-EOP-6, Attachment

18, "Depressurizing

the

RPV," directs that

RCIC be

operated

in accordance

with N2-0P-35,

"Reactor

Core Isolation Cooling,"

to keep the

RPV vented.

'The intent of the step is to operate

RCIC in the

full flow test

mode;

however,

N2-OP'-35

does

not contain

a section that

directs operation of RCIC in the full flow test

mode.

Operators

were

generally

aware of how to perform this routine task.

N2-EOP-6,

Attachment

19,

"RWCU Boron Injection," requires actions to'e

performed in the

RWCU precoat

room.

Access to the

RWCU precoat

room is

severely restricted

by tanks',

pipes

and valves.

About half of this

equipment is required to use

a two component

mix (resi n and filter

media) in the

RWCU filter-demineralizers.

The licensee

now uses

a

single component mixture (e.g.,

ECODEX), thus eliminating the

need for

half of the

equipment= in the

room.

A modification had

been

developed -by

the licensee

to remove the obsolete

equipment.

Steps

19.10 through 19.16 of N2-EOP-6, Attachment

19,

"RWCU Boron Injec-

tion," do not provide clear direction to backwash

the

second demineral-

izer used for boron addition.

The substeps

within step

19.9 of N2-EOP-6, Attachment

19,

"RWCU Boron

Injection," could lead to confusion

as to when to commence

the filter-

demineralizer

precoat cycle.

Auxiliary operators

performing the walkdowns expressed

a lack of famili-

arity with the

RWCU Allen-Bradley computer terminal which is used to

reprogram

the timing sequence

of the

system

when implementing

N2-EOP-6,

Attachment

19,

"RWCU Boron Injection.",

There are

no

new flex gaskets

staged for installing the blank flanges

on"

the,

SBGT system

when implementing

N2-EOP-6, Attachment 21, "Containment

Venting:"

N2-EOP-6, Attachment

21, "Containment Venting," contains

no direction to

shut the

SBGT system

fan discharge

damper which is normally open prior

to removing the spoolpiece.

The mechanical

maintenance

tool box in

SBGT room

B which contains

items

necessary

for the performance

of N2-EOP-6, Attachment

21, "Containment

Venting," does

not contain

an inventory list and is apparently

under the

control of maintenance.

As a result,

there is

no assurance

that the

equipment

required to install the

spool

piece will be readily available

when required.

18.

N2-EOP-6, Attachment 23,

"Containment

Level Determination

(above el.

224

ft.)," contains

a "Note" which precludes

determination of containment

water level if containment, pressure

is greater

than

40 psig.

It appears

that this note is not necessary

and could mislead the operators

during

implementation of N2-EOP-C6,

"Primary Containment

Flooding," which directs

actions

based

on containment water level

up to containment

pressures

of at

least 50.7 psig.

The licensee

agreed to evaluate

the

need for the note

and make corrections

as required.

I

25

ATTACHMENT C

HUMAN FACTORS

EXAMPLES

The following examples

are provided to clarify the types of problems identified

in the areas of human factors concerns

described

in Section

7 of this report.

These

examples

are not intended to be viewed as

an inclusive list of all

such

problems

found in the

NMP2 EOPs,

but rather

as

a set of limited examples

of the

types of inadequacies

found through the

human factors analysis.

1.

N2-EOP-6

NMP2

SUPPORT

PROCEDURE

The writer's guide lacks sufficient guidance for structure

and content

of N2-EOP-6.

For example,

Section

10.2 of N2-EOP-5 indicates that each

attachment

should contain action steps,

but provides

no guidance for

'the structure of an action step.

It also indicates that "cautions

and

notes

may be contained

throughout the action steps,"

but provides

no

guidance for structure

or placement of cautions

and notes.

The N2-EOP-5 Support

Procedure

Validation guestionnaire

(used to validate

N2-EOP-6 attachments)

reflects the weaknesses

in the writer's guide.

The

validation checklist asks

the validator "was the terminology consistent

with that used

on the control panels

or other procedures?"

However,

without clear guidance

on the requirements

for terminology used in the

procedure,

consistency

could

mean anything

from an exact representation

of

control panel

labeling 'to noun

names for equipment that the verifier

subjectively judges to hold the

same

meaning

as the plant labeling.

In

addition,

the checklist lacks any way to control

such important aspects

of

as the consistency

of step structure

or level of detail,

as .does the

writer's guide.

N2-EOP-6 contains

numerous

inconsistencies

in structure

and level of

detail.

For example,

in Attachment

19, the format for the "purpose"

section differs from that used in Attachment

15, although the content is

similar.

Also, Attachment

19,

step

19.8 begins with the conditional

phrase "if it is not already running'."

Several

other steps

in this

attachment

are applicable only under certain conditions;

however,

they do

not include the relevant conditional

phrase (e.g.,

19.3

and 19.5).

In

addition,

references

to filter/demineralizers

in this attachment

are not

consistent.

The references

include: "Filter Demineralizers

(F/Ds)" ( step

19. 1); "Filter/Demineralizers" (step 19.3);

and "F/D" (step 19.4).

The

sections

of N2-OP-37 referenced

from Attachment

19 also. include the

references

"filter/demineralizers" (G.'.2), "Flt/Demin" (G. 1.2.2),

and

"filter/demin" (G. 1.2.3).

'

References

to operating

procedures

often failed to indicate the section

or specific steps

to be performed.

For example,

Attachment

19,

step

19.9.f, directs action to start the precoat cycle per N2-0P-37,

section

F.50,

paragraph

5.4,

then directs

the operator to ignore the steps

about

resin addition

and step

5. 14.

Failure to specifically reference

the

4

f

26

appropriate

steps

requires

the operator to read through irrelevant steps

and decide which steps

are necessary.

Direct reference

to the appropriate

step

numbers

would ease

the task and ensure

performance

of the correct

steps.

Numerous

steps

include plant nomenclature

references

that do not match

that found on the plant labels (e.g.,

Attachment

19, step 19.4, references

for filter-demineralizers).

This problem was

even

more prevalent through-

out the referenced

operating

procedure

sections (e.g.,

N2-0P-37, G;1.2.2).

Communication

Between

0 erations

and Trainin

Conflicts in important. definitions were found between

Operations

Depart-

ment documents

and Training Department

documents.

For example,

the

writer's guide definition of the term "execute"

states

"perform the

actions prescribed

in the identified step"

(N2-EOP-5,

page

125)

~

The

definition of "execute"

from Lesson

Plan 02-REQ-006-344-2-20

is to "leave

the step containing the executive instruction

and take the action, speci-

fied in the identified step,

continuing

on through the subsequent

steps

of

that section" (p. 23).

In addition,

the definitions

shown in the writer'

guide

and the lesson

plan differ substantially for the terms "vent" and

"prevent."

P

Operators

had conflicting definitions for important action verbs.

When

asked to define the term "verify," some operators

indicated that the

word essentially

meant "if it isn't so,

make it so."

Others indicated

that the verb did not imply action

even if the expected

condition was

not found.

Others indicated that the necessary

action

was implied if an

operator

was licensed,

but not for a non-licensed

operator.

The writer's guide includes

a number of important definitions for action

verbs that are not included in the related

EOP lesson

plan.

For

example,

the verbs "verify," "close,"

and "control" are not included in

Lesson

Plan 02-REQ-006-344-2-20.

N2-EOP-5

PRODUCTION AND CONTROL OF

NMP2

REVISIONS

The writer'

guide contains

some guidance that is unclear

and not easily

understandable.

For example,

page

43 contains

the criteria for using

a

decision table for creating conditional

steps

rather than using questions

and decision

symbols.

Neither the

NRC team

human factors specialist

nor

the

NMP2

EOP coordinator could understand

this criteria as written.

Also

on page

43, the writer's guide describes

the criteria for including

multiple conditional

statements

in one decision table.

Again, neither of

the two individuals could understand

the guidance.

The writer's guide includes

some directions that are not sufficiently

restrictive to ensure

consistency

and fails to provide guidance for a

number of aspects

of the procedures.

For example:

l

27

The writer's guide briefly mentions

notes

on page

5; however, it

does not'rovide

a definition nor does it clearly describe

the

structure

and placement for notes within the .EOPs.

The writer's guide indicates

on page

57 that references

to tables

" ...

may either

be enclosed

in parentheses

or incorporated into step

wordings."

The writer's guide indicates

the

use of a requirement flag with

symbolic cross-references

(page 46), but fails to address

the proper

placement

or structure of the symbolic cross-references.

a

Although the writer'

.guide addresses

the acceptable

terms for

indicating branches

and cross references,

no method of emphasis

is

provided for this important

EOP component.

Guidance is not provided for the

use of the conjunctive "or," the

requirements

for use of plant nomenclature

in the procedures,

or

the

use of parentheses.

The writer's guide does

not address

the

need for consistent

use of

acronyms or terminology when referring to the

same

equipment or

system.

The writer's guide fails to provide usable criteria for the level

of detail to be included in the procedure

and does

not address

the

need to structure

steps with the

same

meaning identically.

The writer's guide includes

some guidance that is in conflict with NRC

guidance (e.g.,

NUREG-0899,

NUREG-1358,

and

NUREG/CR-5228)

and generally

accepted

good practices for EOPs.

-For example,

the writer's guide allows

the

use of embedded

logic statements

(p. 44).

In addition, it allows

notes,

actions,

and lists to be formatted identically.

The flowpath

structure for concurrent

steps

allows one of the concurrent

paths to

terminate without

a flowline connecting it to the next step to be

performed.

The writer's guide also fails to prohibit the

use of qualifier

phrases

such

as those

beginning with the term "except."

Some differences

were identified between

the

EOP writer's guide

and the

guidance

included in pro'cedure AI-1.0, "Site Procedures

Writer's Guide."

For example,

the definition for the term "vent" differed in each.

Also,

acronyms

used for the

same

system varied within the